Treating Substance Use Disorders

There are a range of potential skills, theories, and techniques that
counselors can use to treat clients who are struggling with substance use.
As you engage with this page, note the foundational role that empathy plays
in the counseling process. While you read through the different treatment
options, consider the extent to which they are congruent with the ways of Conceptualizing Substance Use that we have learned
about. Despite the range of potential treatment options, remission rates for
people with substance use disorders remain relatively low. Review the
meta-analysis on substance use remission that was conducted by Fleury et al.
(2016).

...when standard remission rates were used... an average of slightly
more than one person in two (54%) were in remission from SUDs
after a mean 18 years of substance use. Using conservative remission
rates, remission reached 35% after a mean 17 years of consumption.

List and define foundational skills that are used in motivational
interviewing.

Articulate benefits that harm reduction programs offer to local
communities and people who use substances.

Use resources to look up information on prescription medications that
their clients are taking.

List medications that are used to treat substance use disorders and
prevent overdoses.

Provide referrals to self help programs for clients who want to stop
using tobacco products.

Describe the twelve steps.

Know when it is appropriate to encourage clients to attend AA, NA,
Al-Anon, and Alateen

Sample Conceptualization & Treatment Plan

The sample conceptualization and treatment plan is based on the following
video about Kevin. Please note that the video is provided for the purpose of
creating the sample conceptualization. It is not intended to be an
educational/instructive video.

Conceptualization and Treatment Plan

Humanistic Approaches to Treating Substance Use

Carl
Rogers is a key figure in the humanistic counseling movement, and
many of Rogers' ideas including the importance of warmth, genuineness,
empathy, and positive regard for clients are now foundational in
counseling.

Motivational Interviewing

Motivational interviewing is a widely used, well researched, humanistic counseling
approach that is particularly useful for changing clients' substance
use.

The state of Oregon published a brief handout describing a skills based
approach to motivational interviewing. Check it out here.

Humanistic Substance Use Treatment
Exploration Questions

Briefly summarize the motivational interviewing
process.

How might you use motivational interviewing in your
future work with clients?

Harm Reduction

Substance use disorders are difficult to treat. If we took a group of 100
people with substance use disorders and followed them for 17 years,
somewhere between 1/2 and 1/3 would be in remission (Fleury, et
al., 2016). Harm reduction programs are based on data indicating
that a majority of people with substance use disorders will not stop using
substances.

Harm reduction focuses on preventing consequences from
substance use, rather than abstinence. While there are many potentially
positive consequences associated with harm reduction, such as reduced
HIV/AIDS transmission, there is evidence that mental health
professionals may not embrace harm reduction because of their personal
biases. To learn more about how personal bias can impact treatment
decisions, read Davis and Hawk (2015). Additionally,
members of the general public may also have difficulty setting aside their
biases and life experiences, so that they can conceptualize the
benefits of a harm reduction approach. Further, historic racial and ethnic
tensions may come into play, for example when a community is trying to
decide where to locate harm reduction clinics.

...many countries, (notably in Europe) quickly embraced
harm reduction and the idea of treating drug use as a public health
problem, while the US cut funding for treatment and prevention and
moved instead toward enhanced criminalization, further entrenching
long-standing, disproportionally race-based negative
outcomes...

Harm reduction is a complex process that can be counter-intuitive.
For example, researchers exploring the effects of the Silk Road, a
marketplace that enabled people to easily purchase a wide range
of illicit substances, which would then be shipped directly to their
homes, found that:

Although it was typical among this sample for use to
increase upon access to Silk Road, it was clear that for some
participants, the capacity to more easily satiate desires for drugs
necessitated new practices of self-control...[participant one] P1
explained that..."this whole summer, I've had such abundance. I
really have no desire to take anything anymore". For P1 Silk Road
was a trigger for his drug use to increase dramatically, peak then
decline rapidly... Similarly, P15 related the "ease of making an
occasional order on SR as a treat" to his "decreased desire
to do hard drugs"...

...it is generally accepted that increased availability of drugs is
associated with increased prevalence of use and subsequent harm. Our
study... indicates that there is a more complex story to tell about
how changes in drug availability affect drug use and harm
trajectories.

...there was evidence that consistently high availability reduced
the need for purchasing larger quantities of drugs... This reduction
in hoarding behaviours helped some respondents to moderate their use
and feel more in control of purchases made online... There was also
evidence that the desire for drugs can become satiated after the
honeymoon period triggered by the saturation availability of a
previously scarce drug. For some, high availability may assist them
in maintaining a controlled drug use pattern resulting in reduced
harm, whereas for others, high availability facilitated intense use
and subsequent harm.

These findings suggest that the mere availability of cryptomarkets
for illicit drug transactions does not determine an increased use or
increased harm.

Two versions of the Silk Road have been shut down, however, the Silk Road 3.0
continues to operate. The Silk Road has been estimated to conduct over
one billion dollars of business per year. Check out the Online Markets Unit
to learn more about Silk Road and other online drug markets.

Harm reduction Exploration Questions

What are some of the risks and ethical
considerations for counselors using a harm reduction
approach with clients?

How might a counselor integrate a harm reduction
approach when treating a client whose substance use is interfering
with their daily life?

What harm reduction resources, such as free needle
clinics, are available in your community?

Medical Approaches

As we learned in the Physiology Unit, using substances alters the brain's
neurochemistry. Researchers are developing medical treatments, including
medications and vaccines, to reduce cravings are relapses. The following
interview with Dr. Thomas Kosten describes how vaccines can play a role in
treating substance use disorders.

Prescription Treatments for Substance Use Disorders

While counselors do not prescribe medications, it is important that they
have awareness regarding how prescription medications can interact with
mental health concerns. There are multiple prescriptions that a physician or
psychiatrist may prescribe to a client to ease cravings or withdrawal
symptoms. Some resources for learning about prescriptions include:

Some prescription medications that are used to treat clients with substance
use disorders include:

Disulfiram (Antabuse)

Used with clients who are motivated to cease using alcohol. Taking
alcohol in conjunction with, or for up to 14 days after,
Disulfiram produces severe side effects including vomiting, headaches,
chest pain, and difficulty breathing.

Suboxone

used to treat opioid cravings and as a maintenance treatment for
people who are addicted to opioids. Suboxone contains an opioid
agonist (buprenorphine) combined with an opioid antagonist
(naloxone).

Naloxone (Narcan)

An opioid antagonist that can be used to reverse opioid
overdoses. Naloxone blocks opioids' effects, so it can result in a
person with an opioid use disorder immediately experiencing withdrawal
symptoms. Naloxone is approved for use in infants and neonates who are
experiencing opioid overdoses.

The United States Surgeon General has issued guidance regarding the
importance of expanding access to Naloxone, as doing so could save
many lives. The Surgeon General's statement is available here.

Methadone hydrochloride

Methadone is an opioid agonist that is prescribed as a maintenance
treatment for clients with opioid use disorders.

Residential Treatment Programs

This section is coming soon.

Abstinence vs Moderation

This section is coming soon.

Smokefree.gov (self-help)

In response to the health concerns associated with tobacco use, the
United States federal government launched smokefree.gov, so that people can access
strategies, resources, information, and support as they cease using
tobacco. Services offered through the website include articles on the
health risks associated with smoking, quizzes, a savings calculator, a
craving journal, apps to set a quite date, and phone and text
support. Visitors have the option of signing up to receive between three
and five text messages per day for six to eight weeks

As you review the resources on smokefree.gov, consider the theories that were used
to develop the resources. For example, encouraging people to
manage nicotine cravings by choosing to spend free time in smoke free
venues is a behavioral suggestion. Calling a counselor is
probably more interpersonal or humanistic. Articles on the benefits
associated with quitting smoking are psychoeducational.

Tobacco Hotlines

877-44U-QUIT (877-448-7848)The
National Cancer Institute's trained
counselors provide information and support for quitting in English and
Spanish. Call Monday through Friday 9:00 a.m. to 9:00 p.m. Eastern
Time.800-QUIT-NOW (800-784-8669)All
states have quitlines with
counselors who are trained specifically to help smokers quit. Call this
number to connect directly to your state's quitline. Hours of operation
and services vary from state to state.(smokfree.gov)

Smokefree.gov Exploration Questions

What theories seem to be most influential in creating the
smokefree.gov
website?

How might a counselor use the resources on the smokefree.gov website
when working with a client who is attempting to stop using
nicotine?

12 Step Programs

12-step models have been used to treat substance use disorders for
many decades. Examples of 12- step programs include AA, NA, and
Al-Anon. Al-Anon uses a 12-step program to support friends
and family members of people who use substances. Alateen is similar
to An-Anon, however, their services are targeted toward children and teens.

The 12-steps are:

We admitted we were powerless over alcohol-that
our lives had become unmanageable.

Came to believe that a Power greater than ourselves
could restore us to sanity.

Made a decision to turn our will and our lives over to
the care of God as we understood Him.

Made a searching and fearless moral inventory of
ourselves.

Admitted to God, to ourselves, and to another human
being the exact nature of our wrongs.

Were entirely ready to have God remove all these
defects of character.

Humbly asked Him to remove our shortcomings.

Made a list of all persons we had harmed, and become
willing to make amends to them all.

Made direct amends to such people wherever possible,
except when to do so would injure them or others.

Continued to take personal inventory and when we were
wrong promptly admitted it.

Sought through prayer and meditation to improve our
conscious contact with God as we understood Him, praying only
for knowledge of His will for us and the power to carry that out.

Having had a spiritual awakening as the result of
these steps, we tried to carry this message back to alcoholics, and to
practice these principals in all our affairs.

Narcotics Anonymous

We offer recovery from the effects of addiction through
working a twelve-step program, including regular attendance at group
meetings. The group atmosphere provides help from peers and offers an
ongoing support network for addicts who wish to pursue and maintain a
drug-free lifestyle. Our name, Narcotics Anonymous, is not meant to
imply a focus on any particular drug; NA's approach makes no distinction
between drugs including alcohol. Membership is free, and we have no
affiliation with any organizations outside of NA including
governments, religions, law enforcement groups, or medical and
psychiatric associations. Through all of our service efforts and our
cooperation with others seeking to help addicts, we strive to reach a
day when every addict in the world has an opportunity to experience
our message of recovery in his or her own language and culture.

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